A portion of the glans (head of the penis) with its nerve supply is converted into the clitoris. This sensitive clitoris maintains normal erogenous sexual sensation and allows my patients to have orgasms. Other techniques amputate the glans or invert it into the vagina, usually without maintaining normal sexual sensation; these procedures usually use spongy tissue surrounding the urethra to create a clitoris. During the clitoris creation, I use a small amount of penile skin just below the glans to create a clitoral hood. The testicles are removed.
The skin of the penis is inverted to create a vagina. The depth of the vagina is important to most patients, especially those desiring sexual intercourse. Traditionally, the depth of the vagina is determined by the amount of shaft skin. Since many patients with a smaller penis did not have adequate depth for satisfactory intercourse, they were often disappointed. Skin grafts from the lower flanks or sides were often used, but the graft donor site can cause unsightly scars. Therefore, I routinely use a skin graft from extra scrotal skin and attach it to the deepest part of the penile skin to make the vagina deeper. The skin must be hairless in order to prevent hair growth inside the vagina, so the hair is removed first by multiple electrolysis treatments. Occasionally, a patient may not have sufficient penile shaft skin or scrotal skin for a deep vagina, so flank skin is then also used. Usually this results in a linear scar.
The remaining scrotum is tailored to make the labia majora or outer lips, and various other techniques are used to create labia minora or inner lips. I also spend considerable time performing intricate maneuvers that give the genitalia a more normal appearance and minimize scars. I rarely perform secondary surgery to enhance the appearance, since most of my patients are very happy with their single stage operation.
The electrolysis treatments should be performed on the entire scrotum except for a small area on each side. This allows the use of the maximum amount of scrotal skin for the graft. Even if a scrotal skin graft is not needed, electrolysis should be performed on the area just below the scrotum on the midline. This skin is used as a flap to widen the vagina, so hair growth at this location can be uncomfortable or unsightly. A numbing cream can be used to lessen the discomfort from electrolysis. Laser hair removal is not considered permanent at this time, so it is not recommended. Later hair growth in the vagina can cause problems.